What practice nurses need to know about prostate disease

November, Movember — it's all about highlighting prostate disease, so practice nurses (whether they are 'Mo-Sistas' or not) can expect increased levels of interest in prostate screening. We look at the pros and cons of testing for prostate cancer and the implications for treatment

The month of November is quickly becoming synonymous with Movember — the global movement to sponsor men to grow a moustache to highlight issues pertaining to men's health, including prostate cancer. Since its inception in 2003, the number of Movember supporters has grown from just 30 friends to an astonishing 1.1 million men worldwide in 2012.¹ The original idea began with a group of men from Melbourne, Australia deciding to grow a moustache as a fun way of raising awareness of men's health issues. In 2012, Movember raised £92million for the cause.

In recognition of the aims of Movember, charities such as Prostate Cancer UK are promoting a range of activities related to men's health throughout this month and beyond. As a result practice nurses may find that they are being asked about screening. Recently I have been asked to add the 'prostate cancer blood test' to the blood form issued for the NHS health checks. So what should clinicians advise when asked about the test? Is it the same as or different from encouraging women to attend for smear tests and mammography? In this article we will consider the controversies surrounding the screening programme for prostate cancer and how to assist patients who get a positive test to understand the options when making a decision regarding treatment. We will also touch on the role of practice nurses who are involved in caring for patients who are being treated for the condition.

INCIDENCE AND PREVALENCE

Almost 41,000 men are diagnosed with prostate cancer each year, making it the most common form of cancer in men with one in every four male cancers being prostate cancer. It is more common in men over 50, especially if a first degree relative (father or brother) has been diagnosed with it. Having a family history of prostate cancer can increase the risk of developing the condition approximately 2.5-fold. Afro-Caribbean men are also known to be at higher risk compared with other ethnic groups — three times as many men from African and African Caribbean backgrounds will develop prostate cancer compared with white men. The reasons for this remain unclear but could be genetic. Interestingly, and for reasons that also remain unclear, men with diabetes have a lower risk of developing prostate cancer.² Prostate cancer death rates have dropped 20% in the past 20 years,3 and this is thought to be due to the use of the Prostate Specific Antigen (PSA) blood test; however, the decision whether or not to have the test is not a straightforward one. There is a very useful infographic for patients on the Prostate Cancer UK website.⁴

PREVENTION OR CURE?

There is much advice available on the internet regarding dietary and lifestyle interventions aimed at reducing the risk of prostate cancer. However, there is very little scientific evidence to say which, if any, of these interventions actually make a difference. Common sense advice such as eating healthily, maintaining an acceptable weight, not smoking and keeping alcohol within recommended government targets seems reasonable but does not come with a clear body of evidence to support it. Prostate cancer is more common in the western world and, like type 2 diabetes, its prevalence increases in East Asian men who move to the west compared with those who stay in their country of origin.² This would suggest that the less healthy western diet with greater use of processed foods and fewer natural products could be implicated. According to Prostate Cancer UK, research is ongoing into the potential benefits of specific foods such as soya, pulses, lycopene (found in tomatoes), selenium (from foods such as brazil nuts and fish) and green vegetables such as broccoli, cauliflower, cabbage and spinach in reducing prostate cancer risk.⁵ Conversely, animal products such as saturated fats, meat and dairy may increase the risk.⁶ However, the scientific evidence remains sparse at this stage.

SIGNS AND SYMPTOMS OF PROSTATE DISEASE

The prostate gland encircles the urethra below the bladder and produces seminal fluid. It is a walnut sized gland. In older men the gland can increase in size and this change can be benign or malignant.

The most common symptoms of prostate disease are problems related to passing urine. These may vary from needing to urinate more often, especially at night, to not being able to pass urine at all.⁷ Flow problems may include being slow to start passing urine or poor flow, including a stop-start flow. Some men may suffer from urgency which may then lead to episodes of incontinence. Sexual problems relating to erectile function and ejaculation may also occur. These symptoms may be very difficult for men to discuss, particularly with a female clinician, so it may be advisable to ask men proactively about them as part of an 'MOT' or even the NHS health check. A useful tool for this is the International Prostate Symptom Score chart which can be accessed at www.prostate-cancer.co.uk/ipss.htm. The overall score can help to identify symptoms which may be related to prostate problems and to assess the severity of those symptoms.

SCREENING FOR PROSTATE DISEASE

The commonest method of assessing for prostate disease is the Prostate Specific Antigen (PSA) test. PSA is a protein which is present in most men in small quantities but is seen in increasing quantities if the prostate gland enlarges or changes. A blood test to measure the level of PSA is available to all men over the age of 50. PSA testing, combined with a digital rectal examination (DRE) by a suitably trained clinician should help to identify those men who may be at increased risk of prostate disease. However, a raised PSA level will not indicate which prostate problem is to blame for the rise and may mean that further tests and interventions need to be carried out. In turn, this may result in treatment being given which could be lifesaving — or completely unnecessary. For example, around 75% of men in their 70s will have problems passing urine as the result of an enlarged prostate. These men may have an abnormally high PSA, but only a small proportion will have prostate cancer and a smaller number still will have the aggressive form. For this reason, screening for prostate disease should only be carried out after careful discussion of the pros and cons.

Although there are national screening programmes for breast, cervical and bowel cancer there is no national screening programme for prostate cancer. This is because although the PSA test may reduce the number of deaths from prostate cancer, this may be at the expense of an increasing number of men who will needlessly suffer from the side effects of unnecessary interventions for slow-growing or non-malignant disease. It is also worth remembering that not all prostate cancer sufferers have raised PSA levels. Benign and malignant changes in the prostate gland can cause PSA levels to rise, as can prostatitis. An abnormal PSA, then, is only the start of the investigative highway and decisions will need to be made by the patient, their loved ones and the clinicians involved as to how to proceed, as two out of three men with a raised PSA will NOT have prostate cancer. According to the European Randomised Study of Screening for Prostate Cancer (ERSPC), in order to prevent one death from prostate cancer over the 11 years of the study, 1,055 men had to be invited for screening, with 37 cancers being detected.⁸

Overall, then, it may be advisable to offer the PSA test to those at increased risk such as men with a first degree relative who has had prostate cancer or men from African/Caribbean backgrounds. A history of breast cancer caused by BRCA1 or BRCA2 in a close female relative may also increase the risk of prostate cancer in male members of the same family so these men may also prefer to have the test. The IMPACT study aims to shed more light on this issue.⁹ Men should be advised of factors which may affect PSA readings before they have the test carried out; these include exercise, urine infections and sexual activity in the 48 hours preceding the test.

DIAGNOSING PROSTATE DISEASE

In symptomatic men, both urine and blood tests should be carried out. Urinalysis can identify the presence of a urinary tract infection which may be the cause of symptoms. Urinalysis may also identify the presence of glucose — diabetes can mimic prostate symptoms with frequency and nocturia being evident in both conditions. Blood tests for kidney and liver function, glucose and PSA should also be arranged. DRE should be carried out to assess the size, shape and texture of the prostate. Normal PSA levels are related to age but PSA should generally be less than 3ng/ml in men in their 50s, less than 4ng/ml in men in their 60s and less than 5ng/ml for men in their 70s.

TYPES OF PROSTATE DISEASE

Prostatitis. Symptoms such as low abdominal and back pain, dysuria or pain on ejaculation can be related to acute or chronic prostatitis, which can be bacterial or non-bacterial.¹⁰ Prostatitis tends to affect men under the age of 50. It can be treated with antibiotics, alpha blockers or anti-inflammatory drugs but may recur.¹¹

Benign prostatic hyperplasia (BPH) is also referred to as BPE — benign prostatic enlargement. Around 40% of all men over the age of 50 will have some degree of BPH. As the name suggests it is non-malignant but will still cause a raised PSA level in many cases.

Prostate cancer. Most prostate cancer is very slow growing and may be unlikely to impact on the man's life at all; however, some types are aggressive and can metastasise rapidly without early diagnosis and treatment. In these cases, the sufferer may only present when metastases are causing symptoms such as pain.

REFERRAL

Post-mortem examinations on men over the age of 80 have shown that most men had cancer cells in the prostate gland but were unaware of this fact and died from other causes.¹² At the heart of the controversy around testing for prostate cancer is the fact that many men will develop low grade malignant changes in the prostate gland in their later years. These will never develop into significant disease, and the men affected will remain both asymptomatic and oblivious unless they are screened and found to have a raised PSA. However, if a raised PSA and/or abnormal prostate on DRE have been detected, decisions will need to be made as to whether to investigate further as some forms of prostate cancer can be aggressive and life changing. PSA testing has been shown to reduce death rates from prostate cancer,13 but as already discussed this may be at a cost. Referral to a urologist will allow decisions to be made about further investigations and treatment based on the PSA readings, the DRE findings and the history. A trans-rectal biopsy of the prostate tissue may be carried out using ultrasound to guide the procedure. This is known as TRUS — trans-rectal ultrasound guided biopsy — and is carried out under local anaesthetic as a day case. Assuming that the correct area of the prostate is biopsied, this procedure can help to identify the presence of cancer cells and if they are present, may in some cases show whether they are an aggressive type of cancer or not. However, the test also has some risks such as bleeding and infection and some men find it uncomfortable.

TO TREAT OR NOT TO TREAT?

If a non-aggressive, slow growing cancer is found, the patient will need to decide whether to have further treatment, which may be unnecessary, or whether to opt for active surveillance, also known as watchful waiting, with all of the psychological pressure that might cause. Ongoing monitoring, involving further PSA, DRE and biopsies will be arranged. If an aggressive cancer is found, further tests such as an MRI or CT scan will be ordered to look for any spread. The prostate gland can be surgically removed (via a total prostatectomy or a transurethral resection of the prostate[TURP]) and radiotherapy from outside or within the prostate may be advised. Some men may require testosterone-blocking hormone therapy for their prostate cancer. All of these treatments can be used alone or in combination, depending on the type and stage of cancer that each individual man has been diagnosed with. All treatment options have possible side effects such as urinary incontinence or erectile dysfunction, and these men and their partners will need to discuss all of the reasons for and against each intervention carefully.

HORMONE TREATMENT FOR PROSTATE CANCER

This is an area with which many practice nurses will be familiar. Prostate cancer relies on testosterone to 'feed' it so drug treatments may be used to block testosterone, help shrink the tumour and reduce the risk of recurrence. Although the effects are not permanent, they may last for many years. Current hormone based treatments used for prostate cancer in the UK include luteinising hormone blockers such as leuprorelin, goserelin and histrelin, anti-androgen drugs such as flutamide and bicalutamide, and the gonadotrophin-releasing hormone blocker degarelix. Abiraterone is a newer hormone treatment for advanced prostate cancer which has not responded to standard therapies. It blocks the action of cytochrome p17 which is needed to produce androgens in the body.¹⁴

The side effects of hormone treatments for prostate cancer are related to their effect on testosterone levels and may appear similar to those experienced by women going through the menopause. They include hot flushes, breast tenderness, osteoporosis, weight gain, mood swings and poor memory.

ONGOING REVIEW

PSA tests will be repeated at least annually in men with prostate cancer. Decisions as to whether to continue, stop or amend hormone therapies will be made based on whether the cancer has resolved, is in remission or has recurred. Men who do not have prostate disease may opt for regular checks too but there is no evidence base to indicate the ideal frequency of these tests.

SUMMARY

Prostate enlargement is common in men over the age of 50. This enlargement may be benign or malignant or may be related to prostatitis. The PSA test can help to identify men with prostate problems but is a non-specific test which does not identify the nature or severity of the disorder. DRE allows the clinician to assess the size, shape and texture of the prostate, which can help to inform interpretation of the PSA result, along with the patient's symptoms, profile and family history. Even with further investigations it is not always easy to identify slow growing prostate cancer from more aggressive forms. This means that men and their partners may be faced with making difficult decisions about whether to have life-changing treatment, which may lead to urinary incontinence and erectile dysfunction, and which may never have been necessary. Organisations such as Prostate Cancer UK, Cancer Research UK and Orchid can support the primary care team, the patient and their family in offering information and support to men about whether to be screened and/or treated for prostate cancer.

REFERENCES

1. Movember UK. About Movember. Available at: http://uk.movember.com/about

2. Cancer Research UK (2012). Prostate Cancer Risks and causes. Available at: http://www.cancerresearchuk.org/cancer-help/type/prostate-cancer/about/prostate-cancer-risks-and-causes#brca

3. Office for National Statistics (2011) Cancer survival rates Available from http://www.ons.gov.uk/ons/publications/re-reference-tables.html?edition=tcm%3A77-239726

4. Prostate risk infographic (2013) Available at:http://prostatecanceruk.org/information/who-is-at-risk/infographic-what-is-my-risk

5. Prostate Cancer UK. Can I reduce my risk? Available at: http://prostatecanceruk.org/information/who-is-at-risk/can-i-reduce-my-risk

6. Orchid (2013) Diet and male cancer Available at: http://www.orchid-cancer.org.uk/753/Diet-and-Male-Cancer

7. NHS Choices (2012) Symptoms of prostate cancer Available at: http://www.nhs.uk/Conditions/Cancer-of-the-prostate/Pages/Symptoms.aspx

8. European Randomised Study of Screening for Prostate Cancer (ERSPC) Prostate-Cancer Mortality at 11 Years of Follow-up. N Engl J Med 2012;366:981-990.

9. Cancer Research UK. Identification of Men with a genetic predisposition to ProstAte Cancer; Targeted screening in men at higher genetic risk and controls (IMPACT). Study information available at: http://www.cancerresearchuk.org/cancer-help/trials/a-study-looking-at-screening-for-men-who-are-at-an-increased-risk-of-developing-prostate-cancer

10. NHS Choices (2013) Prostatitis Available at: http://www.nhs.uk/Conditions/Prostatitis/Pages/Introduction.aspx

11. Thakkinstian A, Attia J, Anothaisintawee T, Nickel JC. α-blockers, antibiotics and anti-inflammatories have a role in the management of chronic prostatitis/chronic pelvic pain syndrome. BJU Int 2012;110(7):1014-22.

12. Macmillan (2012) Risk factors and causes of prostate cancer — age Available at: http://www.macmillan.org.uk/Cancerinformation/Cancertypes/Prostate/Aboutprostatecancer/Causes.aspx

13. Schroder FH. Screening and prostate-cancer mortality in a randomized European Study. N Engl J Med 2009;360:1320-8.

14. Cancer Research (2012). About hormone therapy for prostate cancer Available at: http://www.cancerresearchuk.org/cancer-help/type/prostate-cancer/treatment/hormone/about-hormone-therapy-for-prostate-cancer